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Hiccups in patients with cancer: a multi-site, single-institution study of etiology, severity, complications, interventions, and outcomes. BMC Cancer 2022; 22:659. [PMID: 35705907 PMCID: PMC9202213 DOI: 10.1186/s12885-022-09760-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background To our knowledge, previous studies have not investigated hiccups in patients with cancer with detailed patient-level data with the goal of capturing a broad spectrum of hiccup symptomatology. Methods This multi-site, single institution study examined consecutive medical records to better understand hiccups in patients with cancer. Results A total of 320 patients are the focus of this report. The median age of patients when hiccups were first reported in the medical record was 63 years (range: 21, 97 years) with 284 (89%) men and 36 (11%) women. The most common diagnose was gastrointestinal cancer. Hiccups most frequently occurred daily, as seen in 194 patients (62%), and the most common duration was less than 1 week, as seen in 146 patients (47%). However, nine patients had had daily hiccups for greater than 6 weeks, and 5 had symptoms for years. Cited etiology was non-chemotherapy medications in 36 (11%) and cancer chemotherapy in 19 (6%). Complications occurred in approximately a third and included insomnia in 51 patients (16%); hospitalization or emergency department visit in 34 (11%); and musculoskeletal pain in 23 (7%). Baclofen was the single most prescribed agent for hiccup palliation, but 100 patients received more than one medication. Medical procedures, which included acupuncture, paracentesis, or phrenic nerve block, were performed in 5 patients. In 234 patients (73%), the medical record documented hiccup cessation. Conclusions Hiccups appear to be highly problematic in a small subset of patients with cancer with no well-defined palliative approaches.
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Protracted Hiccups Induced by Aripiprazole and Regressed after Administration of Gabapentin. Case Rep Psychiatry 2021; 2021:5567152. [PMID: 33976948 PMCID: PMC8084681 DOI: 10.1155/2021/5567152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022] Open
Abstract
Hiccups are sudden, repeated, and involuntary contractions of the diaphragm muscle (myoclonic contraction). It involves a reflex arc that, once activated, causes a strong contraction of the diaphragm immediately followed by the closure of the glottis translating into the classic "hic" sound. Hiccups can be short, persistent, and intractable depending on the duration. The most disabling hiccups often represent the epiphenomenon of a medical condition such as gastrointestinal and cardiovascular disorders; central nervous system (CNS) abnormalities; ear, nose, and throat (ENT) conditions or pneumological problems; metabolic/endocrine disorders; infections; and psychogenic disorders. Some drugs, such as aripiprazole, a second-generation antipsychotic, can induce the onset of variable hiccups. We describe herein the cases of three hospitalized patients who developed insistent hiccups after taking aripiprazole and who positively responded to low doses of gabapentin. It is probable that aripiprazole, prescribed at a low dosage (<7.5 mg/day), would act as a dopamine agonist by stimulating D2 and D3 receptors at the "hiccup center" level-located in the brain stem-thus triggering the hiccup. On the other hand, gabapentin led to a complete regression of the hiccup probably by reducing the nerve impulse transmission and modulating the diaphragmatic activity. The present case series suggests the use of low doses of gabapentin as an effective treatment for aripiprazole-induced hiccups. However, our knowledge of the neurotransmitter functioning of the hiccup reflex arc is still limited, and further research is needed to characterize the neurotransmitters involved in hiccups for potential novel therapeutic targets.
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Abu-Hassan AA, Ali R, Derayea SM. A new convenient methodology based on dihydropyridine derivative for selective fluorimetric analysis of baclofen: Application to spiked urine and content uniformity evaluation. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2021; 248:119165. [PMID: 33223435 DOI: 10.1016/j.saa.2020.119165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 05/21/2023]
Abstract
Baclofen belongs to skeletal muscle relaxant and is used for the treatment of muscle spasticity that originated from multiple sclerosis or a spinal cord injury and other cases as hiccups. In the current analytical study, a new, convenient and selective fluorimetric method for baclofen analysis has been developed and validated. The analytical methodology depends on Hantzsch reaction that leads to formation of dihydropyridine fluorescent derivative. The primary amino moiety in baclofen condensed with two equivalents of acetylacetone in the presence of formaldehyde and acetate buffer solutions. Spectrofluorimetric monitoring of the product was accomplished at emission wavelength of 477.3 nm after excitation at 419.9 nm. The method exhibited linearity when baclofen concentration plotted against the fourescence response in the range of 0.3-6.0 µg/mL. Adjustment of the reaction variables and studying validation parameters according to directives of ICH were performed perfectly. Ultimately, the proposed approach was applied successfully for baclofen analysis in raw material, dosage form and spiked urine and it was also extended to test content uniformity.
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Affiliation(s)
- Ahmed A Abu-Hassan
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt.
| | - Ramadan Ali
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Sayed M Derayea
- Department of Analytical Chemistry, Faculty of Pharmacy, Minia University, Minia 61519, Egypt
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Abu-Hassan AA, Ali R, Derayea SM. A new feasible approach based on utility of ninhydrin for selective fluorimetric analysis of baclofen. Application to content uniformity evaluation. LUMINESCENCE 2020; 36:588-594. [PMID: 33140532 DOI: 10.1002/bio.3976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 11/11/2022]
Abstract
In the current proposed analysis, a new, feasible, and selective fluorimetric approach was designed for baclofen assay. Baclofen is a medication prescribed as a therapy for muscle spasticity that originated from multiple sclerosis or a spinal cord injury, and other cases such as hiccups. The analytical approach relies on the use of ninhydrin to form a fluorescent derivative that was monitored at λex 386 nm or λem 480 nm. Under suitable reaction conditions, the primary amino moiety in baclofen was condensed with ninhydrin and phenylacetaldehyde in the presence of Teorel buffer as a buffered medium. The method exhibited linearity when baclofen concentration was plotted against response in the range 1-10 μg ml-1 . Adjustment of the reaction variables and study of validation parameters according to ICH directives were performed correctly. An interference study was implemented to ensure that no discrepancy from the excipient had occurred. Finally, the proposed method was applied successfully for baclofen assay in dosage form and extended to test Mylobac content uniformity.
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Affiliation(s)
- Ahmed A Abu-Hassan
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut, 71524, Egypt
| | - Ramadan Ali
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut, 71524, Egypt
| | - Sayed M Derayea
- Department of Analytical Chemistry, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
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Straus C, Teulier M, Morel S, Wattiez N, Hajage D, Giboin C, Charbit B, Dasque E, Bodineau L, Chenuel B, Straus N, Attali V, Similowski T. Baclofen destabilises breathing during sleep in healthy humans: A randomised, controlled, double-blind crossover trial. Br J Clin Pharmacol 2020; 87:1814-1823. [PMID: 32986891 DOI: 10.1111/bcp.14569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/31/2020] [Accepted: 09/13/2020] [Indexed: 11/29/2022] Open
Abstract
AIMS Periodic breathing is frequent in patients with severe heart failure. Apart from being an indicator of severity, periodic breathing has its own deleterious consequences (sleep-related oxygen desaturations, sleep fragmentation), which justifies attempts to correct it irrespective of the underlying disease. Animal models and human data suggest that baclofen can reconfigure respiratory central pattern generators. We hypothesised that baclofen, a GABAB agonist, may thus be able to correct periodic breathing in humans. METHODS Healthy volunteers were exposed to hypoxia during sleep. Participants who developed periodic breathing (n = 14 [53 screened]) were randomly assigned to double-blind oral baclofen (progressively increased to 60 mg/d) or placebo. The primary outcome was the coefficient of variation (CoVar) of respiratory cycle total time considered as an indicator of breathing irregularity. Secondary outcomes included the CoVar of tidal volume, apnoea-hypopnoea index, sleep fragmentation index and ventilatory complexity (noise limit). RESULTS The analysis was conducted in 9 subjects after exclusion of incomplete datasets. CoVar of respiratory cycle total time significantly increased with baclofen during non-rapid eye movement sleep (median with placebo 56.00% [37.63-78.95]; baclofen 85.42% [68.37-86.40], P = .020; significant difference during the N1-N2 phases of sleep but not during the N3 phase). CoVar of tidal volume significantly increased during N1-N2 sleep. The apnoea-hypopnoea index, sleep fragmentation index and ventilatory complexity were not significantly different between placebo and baclofen. CONCLUSION Baclofen did not stabilise breathing in our model. On the contrary, it increased respiratory variability. Baclofen should probably not be used in patients with or at risk of periodic breathing.
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Affiliation(s)
- Christian Straus
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Département R3S, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, Paris, France
| | - Marion Teulier
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Sébastien Morel
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Nicolas Wattiez
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - David Hajage
- Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, Département de Santé Publique, Unité de Recherche Clinique Salpêtrière-Charles Foix, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Paris, France
| | - Caroline Giboin
- AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Unité de Recherche Clinique Salpêtrière-Charles Foix, Paris, France
| | - Beny Charbit
- INSERM and AP-HP, CIC-1901 module Paris-Est, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Department of Anesthesiology and Intensive Care, CHU Reims, Hôpital Robert Debré, Reims, France
| | - Eric Dasque
- INSERM and AP-HP, CIC-1901 module Paris-Est, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Laurence Bodineau
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Bruno Chenuel
- CHRU de Nancy, Service des Explorations Fonctionnelles Respiratoires et Centre Universitaire de Médecine du Sport et Activité Physique Adaptée, Vandoeuvre-lès-Nancy, France.,Faculté de Médecine de Nancy, EA DevAH - Universié de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Nicolas Straus
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Valérie Attali
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Hôpital Pitié-Salpêtrière, Département R3S, Service des Pathologies du Sommeil, Paris, France
| | - Thomas Similowski
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Hôpital Pitié-Salpêtrière, Département R3S, Service de Pneumologie, Médecine Intensive et Réanimation, Paris, France
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Petroianu GA, Lorke DE. The Role of Serotonin in Singultus: A Review. Front Neurosci 2020; 14:629. [PMID: 32765206 PMCID: PMC7378791 DOI: 10.3389/fnins.2020.00629] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/22/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Georg A. Petroianu
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
- *Correspondence: Georg A. Petroianu,
| | - Dietrich E. Lorke
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
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Sasaki K, Inoue T, Inoue T, Nishijima Y, Endo T, Ezura M, Uenohara H, Niizuma K, Tominaga T. Intractable Hiccups as the Primary Symptom of a Perimedullary Arteriovenous Fistula at the Craniocervical Junction. World Neurosurg 2020; 141:64-68. [PMID: 32526360 DOI: 10.1016/j.wneu.2020.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hiccups are a well-known short-term phenomenon in daily life. If they persist or become intractable, they may be a primary symptom of a disease. Recent studies identified the medulla oblongata as the neuroanatomic center of the hiccup reflex arc. In previous cases, an isolated lesion at the dorsal side of the medulla oblongata induced intractable hiccups. CASE DESCRIPTION We herein describe a patient with a perimedullary arteriovenous fistula (PMAVF) at the craniocervical junction who had intractable hiccups. A 70-year-old male presented with a 3-year history of intractable hiccups that continued for a few days every week. An initial examination failed to identify the underlying cause, and neither medicine nor self-treatment attenuated his symptoms. Intracranial T2-weighted magnetic resonance imaging showed a hyperintensity area within the dorsolateral medulla and flow voids along the dorsal side of the cervical spine. Angiography revealed PMAVF fed by the left C1 radiculomedullary artery. Obliteration of the fistula was performed, after which intractable hiccups had completely disappeared within 1 week. CONCLUSIONS This is the first case report of PMAVF at the craniocervical junction presenting with intractable hiccups that suggested a lesion in the dorsal side of the medulla. The mechanisms underlying hiccups are also discussed.
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Affiliation(s)
- Keisuke Sasaki
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan; Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Tomoo Inoue
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan; Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.
| | - Takashi Inoue
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan
| | - Yasuo Nishijima
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan
| | - Toshiki Endo
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan; Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan
| | - Hiroshi Uenohara
- Department of Neurosurgery, National Health Organization, Sendai Medical Center, Sendai, Miyagi, Japan
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Department of Neurosurgery and Neurosurgical Engineering and Translational Neuroscience, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan; Department of Neurosurgery and Neurosurgical Engineering and Translational Neuroscience, Graduate School of Biomedical Engineering, Tohoku University, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan
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Reichenbach ZW, Piech GM, Malik Z. Chronic Hiccups. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2020; 18:43-59. [PMID: 31974814 DOI: 10.1007/s11938-020-00273-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Nearly 4000 patients will be admitted to hospital in the US this year for hiccups. Hiccups are controlled by a complex reflex arc between peripheral receptors and the brainstem. Any disruption along this pathway may produce hiccups. Typically, hiccups resolve spontaneously but in certain pathologies symptoms may persist. Persistent hiccups may be considered a sign of underlying pathology. The most common cause involves GERD. RECENT FINDINGS Based on etiologies, studies have shown that first-line therapy should use a proton pump inhibitor (PPI) and involve appropriate gastrointestinal consultation. If symptoms persist, other etiologies such as central causes need to be explored. SUMMARY We review the pathophysiology of hiccups including multiple causes and the appropriate work up for each. We review several studies examining new treatments, both pharmacological and interventional, that may help patients. Initial therapy should still involve a PPI but several new therapies may be beneficial.
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Affiliation(s)
- Zachary Wilmer Reichenbach
- Department of Gastroenterology, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad St., 8th floor Parkinson Pavilion, Philadelphia, PA, 19140, USA
- Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Gregory M Piech
- Department of Gastroenterology, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad St., 8th floor Parkinson Pavilion, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Department of Gastroenterology, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad St., 8th floor Parkinson Pavilion, Philadelphia, PA, 19140, USA.
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Abstract
PURPOSE OF REVIEW Singultus or hiccups (HU) is a common, usually temporary, event. Its potentially serious consequences are often overlooked. This review explores published evidence describing HU burden (clinical, economic, and quality of life [QoL] consequences) across patient populations. RECENT FINDINGS Literature review identified 81 articles (including 57 individual case reports). We extracted relevant information to better understand the burden of HU and to identify knowledge gaps for future study. HU are physiologic events that can complicate existing medical conditions and treatments regardless of duration. Relatively short episodes can have devastating consequences in patients who have pre-existing conditions. HU appear to impact physical and psychological health, diminish QoL, increase healthcare resource use, and increase costs. A better understanding of HU burden is needed.
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Pharmacologic Interventions for Intractable and Persistent Hiccups: A Systematic Review. J Emerg Med 2018; 53:540-549. [PMID: 29079070 DOI: 10.1016/j.jemermed.2017.05.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/26/2017] [Accepted: 05/30/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chlorpromazine is the only drug approved by the US Food and Drug Administration for the treatment of hiccups; however, many other pharmacologic treatments have been proposed for intractable and persistent hiccups. Currently, there is little evidence to support the use of one agent over another. OBJECTIVE This review aims to identify literature concerning the use of pharmacologic treatments for intractable and persistent hiccups with the goal of evaluating therapies in terms of their level of evidence, mechanism of action, efficacy, dosing, onset of action, and adverse effects. METHODS A systematic literature search of PubMed, Embase, the Cochrane Library, and the New York Academy of Medicine was performed to find articles where a pharmacologic agent was used to treat intractable or persistent hiccups between the years 1966 and 2016. The GRADE method was used to assess the level of evidence for the studies included in this review. RESULTS This review identified 26 articles involving 10 pharmacologic treatment options that met our inclusion criteria. Amitriptyline, baclofen, gabapentin, haloperidol, metoclopramide, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid were found in the literature to be successful in treating hiccups. CONCLUSION Baclofen, gabapentin, and metoclopramide were the only agents that were studied in a prospective manner, while only baclofen and metoclopramide were studied in randomized controlled trials. No specific recommendations can be made for treating intractable and persistent hiccups with the evidence currently available in the literature. Therapy selection should be specific to individual patients, their underlying comorbidities, etiology of hiccups, and take into account the individual properties of the drugs.
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12
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Wolf E, Kothari NR, Roberts JK, Sparks MA. Baclofen Toxicity in Kidney Disease. Am J Kidney Dis 2017; 71:275-280. [PMID: 28899601 DOI: 10.1053/j.ajkd.2017.07.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/22/2017] [Indexed: 11/11/2022]
Abstract
Baclofen, a commonly prescribed muscle relaxant, is primarily excreted via the kidneys; toxicity is a potentially serious adverse outcome in patients with decreased kidney function. We describe a patient with end-stage kidney disease receiving hemodialysis who developed neurotoxicity and hemodynamic instability after receiving baclofen for muscle spasms. In this case, prompt recognition of baclofen toxicity and urgent hemodialysis were effective in reversing this toxicity. This case is used to examine the pharmacokinetics and pathophysiology of baclofen toxicity and discuss appropriate diagnosis and management of baclofen toxicity. We recommend reducing the baclofen dose in patients who have moderately reduced kidney function (estimated glomerular filtration rate, 30-60mL/min/1.73m2) and avoiding use in patients with severely reduced kidney function (estimated glomerular filtration rate < 30mL/min/1.73m2) or on renal replacement therapy.
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Affiliation(s)
- Erin Wolf
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Niraj R Kothari
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - John K Roberts
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC; Renal Section, Durham VA Medical Center, Durham, NC.
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Persistent Singultus Associated with Lumbar Epidural Steroid Injections in a Septuagenarian: A Case Report and Review. Am J Phys Med Rehabil 2017; 96:e1-e4. [PMID: 27149594 DOI: 10.1097/phm.0000000000000526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Singultus are rare but notable adverse effect of epidural steroid injections (ESIs). To date, reports of persistent hiccups associated with ESIs have been reported mostly in adults aged 65 years or older. We present the first case of persistent hiccups in a septuagenarian who underwent repeated transforaminal ESIs for chronic lumbar radiculopathy. Under fluoroscopic guidance, 1.5 mL of 1% lidocaine (preservative free) and 0.8 mL of dexamethasone solution (10 mg/mL) was injected into the bilateral L4-L5 neural foramen and epidural space.After the first epidural injection, episodes of singultus occurred at a frequency of 5 to 7 episodes per minute and lasted for 36 hours. One month later, he was treated with the second epidural injection after which he immediately developed singultus, occurring at 2- to 3-hour intervals. Interventions for the singultus included drinking small sips of water, vagal maneuvers, and oropharyngeal stimulation with ice chips. The singultus eventually resolved without medical intervention within 5 days of onset. A major take-home point is that preprocedure informed consent should include singultus as one of the potential adverse effects of ESIs. Increased awareness and appropriate planning may help curb the incidence of adverse outcomes in older adults undergoing ESI.
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Persistent Hiccups After an Epidural Steroid Injection Successfully Treated With Baclofen: A Case Report. PM R 2017; 9:1290-1293. [PMID: 28483686 DOI: 10.1016/j.pmrj.2017.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/19/2017] [Indexed: 11/20/2022]
Abstract
Persistent hiccups are an established adverse reaction to epidural steroid injections. Although oral baclofen has been used to treat hiccups in various clinical settings, none of the previously reported studies that used baclofen were related to hiccups occurring after spinal injections/procedures. We report a case of a man who developed persistent hiccups after a transforaminal epidural steroid injection that was treated successfully with oral baclofen. LEVEL OF EVIDENCE V.
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García Callejo FJ, Redondo Martínez J, Pérez Carbonell T, Monzó Gandía R, Martínez Beneyto MP, Rincón Piedrahita I. Hiccups. Attitude in Otorhinolaryngology Towards Consulting Patients. A Diagnostic and Therapeutic Approach. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2017. [DOI: 10.1016/j.otoeng.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Nausheen F, Mohsin H, Lakhan SE. Neurotransmitters in hiccups. SPRINGERPLUS 2016; 5:1357. [PMID: 27588250 PMCID: PMC4988959 DOI: 10.1186/s40064-016-3034-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/10/2016] [Indexed: 11/10/2022]
Abstract
Hiccups are the sudden involuntary contractions of the diaphragm and intercostal muscles. They are generally benign and self-limited, however, in some cases they are chronic and debilitating. There are approximately 4000 admissions for hiccups each year in the United States. The hiccup reflex arc is composed of three components: (1) an afferent limb including the phrenic, vagus, and sympathetic nerves, (2) the central processing unit in the midbrain, and (3) the efferent limb carrying motor fibers to the diaphragm and intercostal muscles. Hiccups may be idiopathic, organic, psychogenic, or medication-induced. Data obtained largely from case studies of hiccups either induced by or treated with medications have led to hypotheses on the neurotransmitters involved. The central neurotransmitters implicated in hiccups include GABA, dopamine, and serotonin, while the peripheral neurotransmitters are epinephrine, norepinephrine, acetylcholine, and histamine. Further studies are needed to characterize the nature of neurotransmitters at each anatomical level of the reflex arc to better target hiccups pharmacologically.
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Affiliation(s)
- Fauzia Nausheen
- Department of Medical Education, California University of Science and Medicine - School of Medicine, 1405 W. Valley Blvd, Suite 101, Colton, CA 92343 USA
| | - Hina Mohsin
- Department of Neurology, California University of Science and Medicine - School of Medicine, Colton, CA USA
| | - Shaheen E Lakhan
- Department of Medical Education, California University of Science and Medicine - School of Medicine, 1405 W. Valley Blvd, Suite 101, Colton, CA 92343 USA ; Department of Neurology, California University of Science and Medicine - School of Medicine, Colton, CA USA
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García Callejo FJ, Redondo Martínez J, Pérez Carbonell T, Monzó Gandía R, Martínez Beneyto MP, Rincón Piedrahita I. Hiccups. Attitude in Otorhinolaryngology Towards Consulting Patients. A Diagnostic and Therapeutic Approach. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2016; 68:98-105. [PMID: 27542994 DOI: 10.1016/j.otorri.2016.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/17/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hiccup crises are generally benign and self-limiting, but longer episodes affect quality of life and must be treated. There are recognisable causes that otorhinolaryngologists must know and be aware for diagnosis and therapeutic alternatives. The main expression is a spasmodic glottic noise with characteristic neck alterations. PATIENTS AND METHODS This was a retrospective study from 1979 with patients suffering persistent or recurrent hiccups. Chronobiology, comorbidity, findings from explorations, therapies and outcomes were noted. Thirty-seven patients were studied (mean age, 45.5±13.5 years; 30 males), with persistent hiccups in 23 (62%). RESULTS A potential associated aetiology was observed in 24 cases (65%): oesophageal disorders -mainly gastroesophageal reflux- were detected in 14 cases and concomitant oncological disease was found in 8. Only 3 cases were admitted for surgery due to these findings. Therapeutic strategies with metoclopramide were used in 18 subjects, chlorpromazine in 17 and baclofen in 13, while carbamazepine or haloperidol were used in a minority. Phrenic nerve stimulation was employed in 6 patients. Hiccups disappeared in 32 cases. Out of 22 cases for which follow-up was possible, the hiccups recurred in 5 subjects (the subjects requiring new therapies) and 11 patients died. CONCLUSIONS Chronic hiccup represents a multidisciplinary challenge that includes potential head and neck affection, a diagnostic schedule for ruling out causes, frequent base oesophageal alterations and high incidence of malignant neoplasm. Prokinetic and neuroleptic agents with antidopaminergic and anticholinergic effects are the pillars of its treatment.
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Affiliation(s)
| | - Jaume Redondo Martínez
- Servicio de Otorrinolaringología, Hospital Clínico Universitario de Valencia, Valencia, España
| | - Tomás Pérez Carbonell
- Servicio de Otorrinolaringología, Hospital Clínico Universitario de Valencia, Valencia, España
| | - Rafael Monzó Gandía
- Servicio de Otorrinolaringología, Hospital General de Requena, Requena, Valencia, España
| | - M Paz Martínez Beneyto
- Servicio de Otorrinolaringología, Hospital Clínico Universitario de Valencia, Valencia, España
| | - Inés Rincón Piedrahita
- Servicio de Otorrinolaringología, Hospital Clínico Universitario de Valencia, Valencia, España
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Hiccup-Like Response in a Dog Anesthetized with Isoflurane. Case Rep Vet Med 2016; 2016:8127496. [PMID: 29955424 PMCID: PMC6005289 DOI: 10.1155/2016/8127496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/23/2016] [Accepted: 06/01/2016] [Indexed: 11/23/2022] Open
Abstract
An eight-year-old, female intact Golden Retriever underwent magnetic resonance imaging (MRI) for investigation of urinary and faecal incontinence. Soon after induction of general anesthesia, tracheal intubation, and isoflurane administration, hiccup-like movements were evident. These hiccup-like movements did not respond to hyperventilation and increase of anesthetic. After having ruled out pulmonary disease, the animal was reanesthetized with a similar technique; hiccup-like movements reoccurred and did not stop after discontinuation of isoflurane and commencement of a propofol infusion. Eventually, a nondepolarizing neuromuscular blocking agent was administered to stop the hiccup-like response and allow MRI to be performed. This case report describes the pathophysiology of hiccup-like response and its management in a dog.
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Development of Hiccup in Male Patients Hospitalized in a Psychiatric Ward: Is it Specifically Related to the Aripiprazole-Benzodiazepine Combination? Clin Neuropharmacol 2016; 39:67-72. [PMID: 26818041 DOI: 10.1097/wnf.0000000000000129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to identify hiccup cases among patients hospitalized in a psychiatric ward and focus on their treatment, so to establish intervention risk. METHODS We reviewed records of 354 consecutively admitted patients during the year 2013 to identify hiccup cases. RESULTS Hiccup occurred in 7 patients on both aripiprazole and benzodiazepines and in one on delorazepam. No patient on aripiprazole alone developed hiccup. No patient on drugs other than aripiprazole or benzodiazepines developed hiccup. The symptom subsided in 3 cases upon discontinuing aripiprazole and in 5 cases after discontinuing the benzodiazepine (including the case on delorazepam alone); in 2 cases of persistent hiccup, the symptom resolved after adding the calcium channel blocker, pregabalin. All patients developing hiccup were male. There was a 70-fold increase in the risk for developing hiccup in the aripiprazole/benzodiazepine intake condition versus all other conditions, and it further increased if limiting to the male sex. LIMITATIONS The retrospective nature of the study was its limitation. CONCLUSIONS Hospitalized psychiatric patients on both aripiprazole and benzodiazepines may be at significant risk of hiccup. This clinical awareness could lead to antipsychotic and/or benzodiazepine discontinuation or switch or to the addition of calcium channel blocker inhibitors.
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Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42:1037-50. [PMID: 26307025 DOI: 10.1111/apt.13374] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 04/26/2015] [Accepted: 07/28/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hiccups are familiar to everyone, but remain poorly understood. Acute hiccups can often be terminated by physical manoeuvres. In contrast, persistent and intractable hiccups that continue for days or months are rare, but can be distressing and difficult to treat. AIM To review the management of hiccups, including a systematic review of reported efficacy and safety of pharmacological treatments. METHODS Available articles were identified using three electronic databases in addition to hand searching of published articles. Inclusion criteria were any reports of pharmaceutical therapy of 'hiccup(s)', 'hiccough(s)' or 'singultus' in English or German. RESULTS Treatment of 341 patients with persistent or intractable hiccups was reported in 15 published studies. Management was most effective when directed at the underlying condition. An empirical trial of anti-reflux therapy may be appropriate. If the underlying cause is not known or not treatable, then a range of pharmacological agents may provide benefit; however, systematic review revealed no adequately powered, well-designed trials of treatment. The use of baclofen and metoclopramide are supported by small randomised, placebo-controlled trials. Observational data suggest that gabapentin and chlorpromazine are also effective. Baclofen and gabapentin are less likely than standard neuroleptic agents to cause side effects during long-term therapy. CONCLUSIONS This systematic review revealed no high quality data on which to base treatment recommendations. Based on limited efficacy and safety data, baclofen and gabapentin may be considered as first line therapy for persistent and intractable hiccups, with metoclopramide and chlorpromazine in reserve.
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Affiliation(s)
- M Steger
- Division of Internal Medicine, University Hospital Zürich, Zürich, Switzerland
| | - M Schneemann
- Division of Internal Medicine, University Hospital Zürich, Zürich, Switzerland
| | - M Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Zürich Center for Integrated Human Physiology, Zürich, Switzerland
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Seidel B, Desipio GB. Use of Osteopathic Manipulative Treatment to Manage Recurrent Bouts of Singultus. J Osteopath Med 2014; 114:660-4. [PMID: 25082974 DOI: 10.7556/jaoa.2014.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Singultus, or hiccups, are involuntary spasms of the diaphragm that in most cases are harmless and self-limited. Treatments are reserved for those cases that persist, and current options include pharmacotherapeutics, complementary methods (such as acupuncture), and osteopathic manipulative treatment. A 32-year-old woman with stiff person syndrome and concurrent aminoacidopathy in the setting of acute inpatient rehabilitation was experiencing daily bouts of singultus, ranging from 20-minute to 5-hour durations. Osteopathic manipulative treatment at the onset of spasm resulted in immediate cessation of and further suppression of singultus for approximately 12 to 24 hours. Overall, there was a noted reduction in singultus frequency, duration, and intensity, as well as better tolerance of physical and occupational therapy. The authors theorize that OMT could be a useful adjunct to, or replacement of, pharmacologic interventions for singultus, especially when pharmacologic therapies have failed.
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Vlavonou R, Perreault MM, Barrière O, Shink E, Tremblay PO, Larouche R, Pichette V, Tanguay M. Pharmacokinetic characterization of baclofen in patients with chronic kidney disease: dose adjustment recommendations. J Clin Pharmacol 2014; 54:584-92. [DOI: 10.1002/jcph.247] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 12/04/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Raphaël Vlavonou
- Division of Clinical Pharmacology; inVentiv Health Clinical; Montreal Quebec Canada
| | - Marc M. Perreault
- Faculty of Pharmacy; Université de Montréal; Montreal Quebec Canada
- Department of Pharmacy; McGill University Health Center; Montreal Quebec Canada
| | - Olivier Barrière
- Division of Clinical Pharmacology; inVentiv Health Clinical; Montreal Quebec Canada
| | - Eric Shink
- Division of Clinical Pharmacology; inVentiv Health Clinical; Quebec Quebec Canada
| | | | - Richard Larouche
- Clinical division; inVentiv Health Clinical; Montreal Quebec Canada
| | - Vincent Pichette
- Centre de recherche Hôpital Maisonneuve-Rosemont; Montréal Canada
- Département de Médecine et de Pharmacologie; Université de Montréal; Montréal Canada
| | - Mario Tanguay
- Division of Clinical Pharmacology; inVentiv Health Clinical; Montreal Quebec Canada
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Baumann A, Weicker T, Alb I, Audibert G. Baclofen for the treatment of hiccup related to brainstem compression. ACTA ACUST UNITED AC 2014; 33:e27-8. [PMID: 24378046 DOI: 10.1016/j.annfar.2013.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 10/22/2013] [Indexed: 11/24/2022]
Affiliation(s)
- A Baumann
- Service de réanimation neurochirurgicale, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France.
| | - T Weicker
- Service d'anesthésie-réanimation chirurgicale, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - I Alb
- Service de réanimation neurochirurgicale, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - G Audibert
- Service de réanimation neurochirurgicale, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
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Moretto EN, Wee B, Wiffen PJ, Murchison AG. Interventions for treating persistent and intractable hiccups in adults. Cochrane Database Syst Rev 2013; 2013:CD008768. [PMID: 23440833 PMCID: PMC6452787 DOI: 10.1002/14651858.cd008768.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Persistent and intractable hiccups (typically defined as lasting for more than 48 hours and one month respectively) can be of serious detriment to a patient's quality of life, although they are relatively uncommon. A wide range of pharmacological and non-pharmacological interventions have been used for the treatment of persistent and intractable hiccups. However, there is little evidence as to which interventions are effective or harmful. OBJECTIVES The objective of this review was to evaluate the effectiveness of pharmacological and non-pharmacological interventions used in the treatment of persistent and intractable hiccups of any aetiology in adults. SEARCH METHODS Studies were identified from the following databases: CENTRAL, CDSR, DARE, MEDLINE, EMBASE, CINAHL, PsychINFO and SIGLE (last search March 2012). The search strategy for all the databases searched was based on the MEDLINE search strategy presented in Appendix 1. No additional handsearching of journals was undertaken. Investigators who are known to be carrying out research in this area were contacted for unpublished data or knowledge of the grey literature. SELECTION CRITERIA Studies eligible for inclusion in this review were randomised controlled trials (RCTs) or controlled clinical trials (CCTs). INCLUSION CRITERIA adults (over 18 years old) diagnosed with persistent or intractable hiccups (hiccups lasting more than 48 hours), treated with any pharmacological or non-pharmacological intervention. EXCLUSION CRITERIA less than ten participants; no assessment of change in hiccup frequency or intensity in outcome measures. DATA COLLECTION AND ANALYSIS Two independent review authors assessed each abstract and title for relevance. Disagreement on eligibility was resolved by discussion. Where no abstract was available the full paper was obtained and assessed. We obtained full copies of the studies which met the inclusion criteria for further assessment. Two review authors independently collected data from each appropriate study and entered them into the software Review Manager 5. Two independent review authors assessed the risk of bias using the RevMan 5 'Risk of bias' table following guidance from the Cochrane Handbook of Systematic Reviews of Interventions (Higgins 2009). MAIN RESULTS A total of four studies (305 participants) met the inclusion criteria. All of these studies sought to determine the effectiveness of different acupuncture techniques in the treatment of persistent and intractable hiccups. All four studies had a high risk of bias, did not compare the intervention with placebo, and failed to report side effects or adverse events for either the treatment or control groups. Due to methodological differences we were unable to perform a meta-analysis of the results. No studies investigating pharmacological interventions for persistent and intractable hiccups met the inclusion criteria. AUTHORS' CONCLUSIONS There is insufficient evidence to guide the treatment of persistent or intractable hiccups with either pharmacological or non-pharmacological interventions.The paucity of high quality studies indicate a need for randomised placebo-controlled trials of both pharmacological and non-pharmacological treatments. As the symptom is relatively rare, trials would need to be multi-centred and possibly multi-national.
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Renal abscess in a patient presenting with persistent hiccups. Case Rep Emerg Med 2013; 2013:459453. [PMID: 23431479 PMCID: PMC3556404 DOI: 10.1155/2013/459453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 12/23/2012] [Indexed: 01/15/2023] Open
Abstract
Hiccups are common, typically limited, and rarely present with adverse complications. In the context of persistent or intractable episodes, however, hiccups may signal a more serious underlying cause. Here, we present an unexpected and pathologic case of hiccups in a patient who was ultimately diagnosed with renal abscesses.
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Byun SH, Jeon YH. Treatment of idiopathic persistent hiccups with positive pressure ventilation -a case report-. Korean J Pain 2012; 25:105-7. [PMID: 22514778 PMCID: PMC3324734 DOI: 10.3344/kjp.2012.25.2.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 12/23/2011] [Accepted: 12/27/2011] [Indexed: 11/20/2022] Open
Abstract
A 41-year-old male patient presented with idiopathic persistent hiccups. The hiccups did not respond to pharmacologic treatments including cisapride, omeprazole, and baclofen. Phrenic nerve block was also ineffective. However, the persistent hiccups were successfully treated with short-term positive pressure ventilation using a short-acting muscle relaxant.
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Affiliation(s)
- Sung Hye Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Eisenächer A, Spiske J. Persistent hiccups (singultus) as the presenting symptom of medullary cavernoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:822-6. [PMID: 22211149 PMCID: PMC3244169 DOI: 10.3238/arztebl.2011.0822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 08/29/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Singultus (hiccup) is common, usually transient, and only rarely indicative of disease. If it persists, it can be highly bothersome, potentially interfering with sleep and leading to depression and physical exhaustion. It is presumed to be due to a disturbance in a reflex arc that includes the brainstem, the phrenic nerve, the vagus nerve, and the sympathetic chain. It can be induced by mechanical irritation (e.g., gastric distention), metabolic or toxic irritation (e.g., alcohol, cigarette smoke), infectious processes, emotional disturbances, and, rarely, neurological diseases. CASE DESCRIPTION The patient presented with persistent singultus (by definition, singultus lasting more than 48 hours). Initial diagnostic tests failed to reveal the cause, and the hiccups failed to respond to medications and other attempted treatments. Finally, an imaging study revealed a medullary cavernoma. After neurosurgical resection of this lesion, the patient was asymptomatic and returned to work. CONCLUSION This case shows that singultus, though it may seem trivial, deserves to be taken seriously, particularly when it persists and does not respond to medications. Its cause can be discovered in timely fashion by means of a thorough clinical history, physical examination, and ancillary testing.
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Seker MM, Aksoy S, Ozdemir NY, Uncu D, Civelek B, Akıncı MB, Zengin N. Successful treatment of chronic hiccup with baclofen in cancer patients. Med Oncol 2011; 29:1369-70. [PMID: 21442315 DOI: 10.1007/s12032-011-9910-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 03/14/2011] [Indexed: 11/28/2022]
Abstract
Chronic hiccup is an infrequent but distressing symptom in patients with advanced cancer. A series of drugs (chlorpromazine, haloperidol, nifedipine, metoclopramide, baclofen) have been used to treat hiccup without definitive results. Some authors have suggested a possible role of baclofen in the treatment of chronic hiccup. We report three cases of chronic hiccup in patients with cancer successfully treated with baclofen.
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Affiliation(s)
- M Metin Seker
- Department of Medical Oncology, Ankara Numune Education and Research Hospital, 06100 Ankara, Turkey
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de Hoyos A, Esparza EA, Cervantes-Sodi M. Non-erosive reflux disease manifested exclusively by protracted hiccups. J Neurogastroenterol Motil 2010; 16:424-7. [PMID: 21103425 PMCID: PMC2978396 DOI: 10.5056/jnm.2010.16.4.424] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Revised: 09/24/2010] [Accepted: 09/30/2010] [Indexed: 01/26/2023] Open
Abstract
Hiccups are a benign physiological feature affecting almost everyone at one time or another. They tend to be short-lived and do not affect quality of life; however, there are various pathologies that may present with long-lasting hiccups. These are grouped into 3 categories according to their duration: acute, persistent and intractable or protracted hiccups. Intractable hiccups last longer than 2 months and are usually associated with more severe conditions. The association between intractable hiccups and reflux disease has not been previously documented by objective methods. This report describes the case of a 23-year-old female who presented with protracted hiccups; all other organic pathologies were ruled out, and endoscopy and conventional pH-metry confirmed a diagnosis of non-erosive reflux disease as the unique cause.
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Affiliation(s)
- Andrés de Hoyos
- Department of Gastroenterology, Angeles del Pedregal Hospital, México City, México
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Cabane J, Bizec JL, Derenne JP. [A diseased esophagus is frequently the cause of chronic hiccup. A prospective study of 184 cases]. Presse Med 2010; 39:e141-6. [PMID: 20427147 DOI: 10.1016/j.lpm.2010.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/13/2010] [Accepted: 01/18/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Chronic hiccup, defined as repetitive hiccup spells during more than 48 h, is an uncommon and neglected pathological condition, in which preliminary findings suggested an upper digestive origin. METHODS We prospectively included 184 rebel chronic hiccups in this clinical and endoscopic study. Our rule of thumb was to consider upper digestive findings as first-rank in imputability and thus to treat them in priority. If treatment failed or no abnormality was found in the upper digestive tract, a neurological survey was done and baclofen tried. RESULTS We thus discovered upper digestive abnormalities in 80% of the patients and the treatment rule yielded 66% of success, including 48 complete remissions and 116 partial remissions. There were 20 failures, generally due to untreatable neurological diseases such as brain tumors. CONCLUSION A diseased esophagus is frequently the cause of chronic hiccup.
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Affiliation(s)
- Jean Cabane
- Service de médecine interne horloge 2, hôpital Saint-Antoine, AP-HP, faculté de médecine Pierre-et-Marie-Curie Paris-6, 75571 Paris cedex 12, France.
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Lee JH, Kim TY, Lee HW, Choi YS, Moon SY, Cheong YK. Treatment of intractable hiccups with an oral agent monotherapy of baclofen -a case report-. Korean J Pain 2010; 23:42-5. [PMID: 20552072 PMCID: PMC2884207 DOI: 10.3344/kjp.2010.23.1.42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 09/06/2009] [Accepted: 09/11/2009] [Indexed: 11/06/2022] Open
Abstract
Hiccups are an involuntarily powerful spasm of the diaphragm, followed by a sudden inspiration with a closure of the glottis. Hiccups that are caused by gastric distention, spicy foods and neural dysfunction can resolve themselves without any treatment. Some hiccups are associated with certain diseases or they occur postsurgically, and life-restricting intractable hiccups should be treated. The cause of hiccups should be quickly determined so as to administer the proper treatment. Hiccups often remit spontaneously within a short period of time, but they may also occur without remission for a prolonged period in some cases. We report here on a 36-year-old man who suffered with intractable hiccups for 5 years. We administered a single oral dose of baclofen, and then the hiccups disappeared. We conclude that a single dose of baclofen is a good treatment for intractable hiccups.
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Affiliation(s)
- Ju Hwan Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Wonkwang University, Iksan, Korea
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Tay SS, Yadav RR. Novel Use of Baclofen in Cancer Patients for the Treatment of Hiccups. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2010. [DOI: 10.47102/annals-acadmedsg.v39n2p154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Froestl W. Chemistry and Pharmacology of GABAB Receptor Ligands. GABABRECEPTOR PHARMACOLOGY - A TRIBUTE TO NORMAN BOWERY 2010; 58:19-62. [DOI: 10.1016/s1054-3589(10)58002-5] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Jatzko A, Stegmeier-Petroianu A, Petroianu GA. Alpha-2-delta ligands for singultus (hiccup) treatment: three case reports. J Pain Symptom Manage 2007; 33:756-60. [PMID: 17360149 DOI: 10.1016/j.jpainsymman.2006.09.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Revised: 09/21/2006] [Accepted: 09/22/2006] [Indexed: 11/29/2022]
Abstract
Chronic idiopathic singultus (hiccup) is a debilitating condition affecting mostly elderly males. While in the past, pharmacologic singultus treatment was mostly "trial and error," more recently, treatment has become both more evidence based and pathophysiology guided. A combination of an acidity-reducing drug (H(2)-receptor blocker or proton pump inhibitor) with baclofen (gamma-amino-butyric-acid receptor type B agonist) has become the most widely used regimen. Some clinicians replace or supplement baclofen with gabapentin. We present three cases of chronic idiopathic hiccup managed with gabapentin or another alpha-2-delta ligand, pregabalin. This is the first reported use of pregabalin for this indication.
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Garrigues P, Giovansili B, Villard F, Coquery ML, Bellahouel S, Duc P, Champetier de Ribes D. [Renal cyst inducing hiccups]. Presse Med 2007; 36:239-42. [PMID: 17259033 DOI: 10.1016/j.lpm.2006.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Accepted: 07/27/2006] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Hiccups are a sudden, irregular and spasmodic contraction of the diaphragm followed by an abrupt closure of the glottis. Besides etiologic treatment, its management is above all symptomatic and based primary on medical treatment. CASE We report a case of chronic hiccups associated with an abscessed voluminous renal cyst. Drainage of the cyst resolved the hiccups. DISCUSSION Various symptomatic treatments failed because the hiccups were due to irritation of the phrenic nerve by an abscessed renal cyst. This case reminds us that an extensive etiologic work-up may be necessary when symptomatic treatment of hiccups is ineffective.
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Affiliation(s)
- Philippe Garrigues
- Service de médecine interne, Hôpital du Perpétuel Secours, Levallois-Perret (93).
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McAllister RK, McDavid AJ, Meyer TA, Bittenbinder TM. Recurrent persistent hiccups after epidural steroid injection and analgesia with bupivacaine. Anesth Analg 2005; 100:1834-1836. [PMID: 15920222 DOI: 10.1213/01.ane.0000153016.82444.20] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This case report presents a patient who developed persistent hiccups after epidural administration of dilute bupivacaine on several different occasions. Substitution of saline for the dilute bupivacaine during epidural steroid injection did not result in hiccups; however, subsequent postoperative epidural analgesia with bupivacaine caused a recurrence of the hiccups.
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Affiliation(s)
- Russell K McAllister
- Department of Anesthesiology, Scott and White Memorial Hospital and Clinic; Scott, Sherwood and Brindley Foundation; The Texas A&M University System Health Science Center College of Medicine; Temple, Texas
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You SH, Kim CS, Kim BH, Seo HJ, Kang KS. Treatment of Persistent Hiccups with a Single Session of Gabapentin Therapy -A report of 2 cases-. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.2.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Sie Hyun You
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Chun Sook Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Bung Heum Kim
- Department of Orthopedics, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Hwan Joo Seo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Kyu Sik Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
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Moretti R, Torre P, Antonello RM, Ukmar M, Cazzato G, Bava A. Gabapentin As A Drug Therapy of Intractable Hiccup Because of Vascular Lesion: A Three-Year Follow Up. Neurologist 2004; 10:102-6. [PMID: 14998440 DOI: 10.1097/01.nrl.0000117824.29975.e7] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Persistent and intractable hiccups indicate multiple neurologic and extraneurologic disorders. Chronic hiccup is not so rare in patients suffering from stroke: its impact on quality of life and on rehabilitation management is substantial, and it may be closely related to aspiration pneumonia, respiratory arrest and nutritional depletion. REVIEW SUMMARY Intractable hiccups can be associated with potentially fatal consequences and safe management may require inpatient rehabilitation. It has been suggested that hiccups could be a form of myoclonus, caused by repeated and abnormal activity of the solitary inspiratory nucleus. Because of this cause we decided to treat intractable hiccups in patients with ischemic lesions of the medulla with a short course of gabapentin. CONCLUSIONS The results were promising, with the immediate disappearance of the hiccups, and the complete absence of side effects. The 36-months follow up was favorable to all the patients, who, after 6 days of treatment remain asymptomatic.
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Affiliation(s)
- Rita Moretti
- Dipartimento di Fisiologia e Patologia, Università degli Studi di Trieste, Italy.
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Oshima T, Dohi S. Isoflurane Facilitates Hiccup-Like Reflex Through Gamma Aminobutyric Acid (GABA)A- and Suppresses Through GABAB-Receptors in Pentobarbital-Anesthetized Cats. Anesth Analg 2004; 98:346-352. [PMID: 14742368 DOI: 10.1213/01.ane.0000097169.98992.e7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED The mechanism by which volatile anesthetics exert inconsistent effects on hiccups is unknown. We elicited a hiccup-like reflex by mechanical stimulation of the dorsal epipharynx in mechanically ventilated cats. The magnitude of the hiccup-like reflex was measured as the peak negative esophageal pressure (nPes) generated against an occluded airway. First, we examined the effects of different end-expiratory concentrations of isoflurane on nPes. Second, we determined the effects of 1.0 minimum alveolar anesthetic concentration of isoflurane on nPes after a peripherally restricted gamma aminobutyric acid (GABA)(A)-receptor antagonist, bicuculline methiodide (BM), a GABA(B)-receptor antagonist, CGP 35348, a peripherally restricted GABA(B)-receptor antagonist, CGP 54626, or saline had been administered IV. Third, BM, CGP 35348, or artificial cerebrospinal fluid was administered intracisternally before 1.0 minimum alveolar anesthetic concentration of isoflurane exposure. During isoflurane anesthesia, nPes was inversely proportional to the end-expiratory isoflurane concentration. The rank order of nPes values obtained after IV drug pretreatment and isoflurane exposure was BM < saline < CGP54626 < CGP35348. After intracisternal drug pretreatment and isoflurane administration, the order of nPes was BM < artificial cerebrospinal fluid < CGP35348. Isoflurane modulates the hiccup-like reflex in opposite directions through both central and peripheral GABA(A) and GABA(B) receptors, with the net effect being a dose-dependent suppression. IMPLICATIONS Isoflurane facilitated the hiccup-like reflex through activation of central and peripheral gamma aminobutyric acid (GABA)(A) receptors but suppressed it via activation of central and peripheral GABA(B) receptors. The net result was that the hiccup-like reflex was inhibited in proportion to the alveolar isoflurane concentration.
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Affiliation(s)
- Tsutomu Oshima
- Department of Anesthesiology and Critical Care Medicine, Gifu University School of Medicine, Gifu-City, Japan
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Abstract
There are close to a hundred causes for hiccups, or singultus, the most common of which are gastrointestinal. Causes may be natural or drug induced, and the same agents that are used to treat hiccups may also induce them. Hiccups can be classified by their duration, as follows: up to 48 hours, acute; longer than 48 hours, persistent; and more than two months, intractable. Treatment options for hiccups can include both pharmacologic and nonpharmacologic agents. If the cause of hiccups can be identified, it is, of course, preferable to direct the treatment at that cause. However many times a cause cannot be identified; in this case, general measures or treatments should be instituted. Intractable hiccups can occur in the palliative care population. When they do, it can be extremely distressing and have a significant impact on quality of life. Pharmacologic approaches are often the most rational therapies for these patients. Baclofen seems to be a promising drug for use with both palliative care and perioperative patients, and using garabentin as an add-on to baclofen may also be a reasonable option to consider
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Affiliation(s)
- Howard S Smith
- Presbyterian University Hospital, University of Pittsburgh Medical Center, Pennsylvania, USA
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Katsinelos P, Pilpilidis J, Xiarchos P, Christodoulou K, Papagianis A, Amperiadis P, Eugenidis N. Baclofen therapy for intractable hiccups induced by ultraflex esophageal endoprosthesis. Am J Gastroenterol 2000; 95:2986-7. [PMID: 11051387 DOI: 10.1111/j.1572-0241.2000.03216.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Straus C, Wilson RJ, Tezenas du Montcel S, Remmers JE. Baclofen eliminates cluster lung breathing of the tadpole brainstem, in vitro. Neurosci Lett 2000; 292:13-6. [PMID: 10996438 DOI: 10.1016/s0304-3940(00)01422-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intermittent lung ventilation is a respiratory pattern wherein breaths occur in clusters. Intermittent lung ventilation is common in amphibians and can occur in mammals. Isolated brainstems from postmetamorphic tadpoles exhibiting episodic lung ventilatory bursts were superfused with baclofen, a potent gamma-aminobutyric acid (GABA)(B) receptor agonist. At moderate concentrations (0.125 to 0.5 microM), the number of lung bursts per episode decreased but their overall frequency was unchanged. At 0.5 microM, only 1.22+/-0.24 lung bursts occurred per episode, indicating virtually no clustering. Only at higher concentrations was overall breathing frequency decreased. Therefore, at moderate concentrations of baclofen continuous ventilation replaced episodic ventilation, suggesting that a GABA(B) receptor-dependent pathway may regulate the clustering of lung breaths.
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Affiliation(s)
- C Straus
- Respiratory Research Group, Department of Medical Physiology, Faculty of Medicine, University of Calgary, 3330 Hospital Drive NW, Alberta, T2N 4N1, Calgary, Canada.
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Petroianu G, Hein G, Stegmeier-Petroianu A, Bergler W, Rüfer R. Gabapentin "add-on therapy" for idiopathic chronic hiccup (ICH). J Clin Gastroenterol 2000; 30:321-4. [PMID: 10777198 DOI: 10.1097/00004836-200004000-00025] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The efficacy of cisapride, omeprazole, and baclofen (COB) for treatment of idiopathic chronic hiccup (ICH). was proven in several studies. The combination is considered, at present, to be "therapy of choice" for this condition. Substituting gabapentin for baclofen in baclofen resistant ICH cases can occasionally be successful. We present here cases where gabapentin was used successfully in combination with cisapride and omeprazole (COG/one patient) or as an "add-on" with cisapride, omeprazole, and baclofen (COBG/three patients). We conclude that, with baclofen and gabapentin, we are in possession of two substances that are, as a part of a combination therapy, quite effective for ICH. Because of the far more extensive experience with baclofen, we use it as a first-line therapy, together with omeprazole and cisapride. In cases where the results are not entirely satisfactory, the addition of gabapentin should be considered.
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Affiliation(s)
- G Petroianu
- Department of Pharmacology and Toxicology, University of Heidelberg at Mannheim, Germany
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Petroianu G, Hein G, Petroianu A, Bergler W, Rüfer R. Idiopathic chronic hiccup: combination therapy with cisapride, omeprazole, and baclofen. Clin Ther 1997; 19:1031-8. [PMID: 9385490 DOI: 10.1016/s0149-2918(97)80055-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Idiopathic chronic hiccup (ICH) is defined as recurring hiccup attacks that last for longer than an arbitrary time limit (eg, 1 month) and for which no organic cause can be found. In patients with ICH, therapy is largely empiric. For practical purposes, idiopathic hiccup can be assumed to have its origin either in the viscera (gastrointestinal tract) or in the central nervous system. Cisapride and omeprazole--through reduction of gastric acid production and facilitation of gastric emptying, respectively--are thought to reduce an assumed afferent input from the periphery to a putative supraspinal hiccup center. Baclofen is thought to reduce excitability and depress reflex hiccup activity. Fifteen male patients (mean [+/- SD] age, 68.2 +/- 11.6 years) who had recurring hiccup attacks for a mean duration of 100.8 +/- 134.1 months (range, 12 to 564 months) were treated for ICH with a combination of cisapride, omeprazole, and baclofen (COB). Therapy led to a total disappearance of hiccup in 40% (6 of 15) of the treated patients. An additional 20% (3 of 15) of patients experienced substantial relief. A Mann-Whitney rank order test showed a highly significant reduction in the severity of the hiccup attacks as reflected in the subjective assessment scale scores taken before therapy (8.6 +/- 1.3) compared with those taken after 20 weeks of therapy (4.1 +/- 3.8). Thus we concluded that COB is an effective empiric therapy in at least some patients with ICH.
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Affiliation(s)
- G Petroianu
- Department of Pharmacology and Toxicology, University of Heidelberg at Mannheim, Germany
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